Consultation Form: Coffeeberry Peel NAME: ADDRESS: TELEPHONE NUMBER: DATE OF BIRTH: EMERGENCY CONTACT: EMAIL ADDRESS: OCCUPATION: DOCTORS NAME/SURGERY: We aim to ensure clients have the best possible advice both prior to and post-treatment. Please read the following information prior to booking an appointment in the salon. Consultation Information: to ensure you are not contraindicated to any treatment. Pretreatment Advice: should be read prior to attending an appointment. Aftercare Advice: to be read following your appointment for best results. Children under the age of 16 should have consent from a parent or guardian prior to any appointment. CONSULTATION FACIAL PEEL CoffeeBerry Natureceuticals Do you have any of the following? Psoriasis Hay Fever
Diabetes Bronchitis Asthma Sensitive Skin Dandruff Dermatitis Eczema Acne Dry Skin Sensitive Eyes Herpes, Cold Sores or Fever Blisters Are you presently using or taking any prescription drugs for a skin condition? (Such as Accutane, Tazorac, Retin-A, Antibiotics, and Corticoid Steroid) Have you ever taken any of these drugs for a skin condition in the past? Do you have any other skin conditions? Please explain: Are you allergic or have you ever had any adverse reactions to medications? If yes, what type? Are you allergic to or have you ever had an adverse reaction to cosmetics, foods, clothing, soap, shampoo, hair dye, perfumes or jewelry? Yes/No If yes, to what? Are you currently taking any medication? If yes, what kind? Have you had any medical/health problems occur recently? LIFESTYLE Did you go on holiday recently, where your skin faced a dramatic climatic change? (Sun, snow, wind etc) Yes/No If yes, please explain: Have you recently had any change in your diet, lifestyle or
beauty regime? Yes/No If yes, please explain: Have you used active skincare products in the past, or are you presently using active skincare products such as Alpha Hydroxy or Retinol? Pre Chemical Peel Contraindications That Indicate Peel Should Not Be Performed: Inflamed Acne Cyst Recent Retin-A Use Roacutane Use Pregnant or Nursing Open Wounds Sunburned Skin Allergy to Aspirin Severe Physical or Mental Stress Allergy to PRIORI homecare products Allergy to hair dyes Active Herpes Recent Hair Removal (48 hours) Irritated or Damaged Skin Clay Masks, Scrubs or Additional Agents (48 hours) Please note that the peel procedure can remove self-tanning products. Microdermabrasion, laser resurfacing or other facial treatments such as chemical peels, Botox, skin fillers, laser skin treatments or plastic surgery should be completely healed before proceeding with many PRIORI Skincare treatments. Skin Indications For The Peels (reason for the peel to be performed) Acne/Acne Scarring Facial Erythema Blocked Pores/Follicles Photo Damage Dry, Dehydrated Skin Dull Skin
Fine Lines Improve Skin Texture Priori Product Prior Use: If you have a history of sensitive skin please confirm that you have been using Priori skincare for two weeks prior to tis treatment taking place and please identify which products you have been using.. Please ensure: All other facial treatment procedures used outside the 48 hours should have left the skin completely healed and normalized before having an Idebenone peel. The skin care specialist has explained the peel and contraindications of this form to me and I fully understand and agree with the consultation. I understand a mild redness or slight irritation may occur temporarily and subside. I must wait 48 hours before using the Idebenone Priori Eye Serum, and 24 hours before using any other Idebenone Priori homecare or other skincare products. I understand maximum results from the peels will be achieved with a course- generally 6 peels, in conjunction with homecare products. I understand due to the variable nature of the skin, no guarantee can be made to me regarding the results of the treatment. I confirm that I have received a copy of the pre and post peel instruction sheet. On completion of this consultation card you must tick the Consent Box in order for the treatment to take place. By ticking the box, you are agreeing to the following terms and conditions. I accept that any treatment I have has been fully explained to me and will be undertaken at my own risk. I have carried out a patch test (where necessary) and I am satisfied with the explanation of the procedure and the aftercare. I have answered the questions regarding my medical history to the best of my knowledge and accept that failure to disclose
relevant information may impact treatment results. I agree to contact Sutherlands Hair and Beauty immediately in the event of any adverse effects. I agree to these terms and conditions (Please tick)